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OPIOIDS IN CHRONIC NONMALIGNANT PAIN
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R. Portenoy, MD, Memorial Sloan Kettering Cancer Center (MSKCC), New
York City, proposes reappraising the traditional prescribing of opioid
drugs. This recommendation is based on a review of the literature on
substance abuse and chronic pain. Careful patient evaluation before and
during treatment of nonmalignant pain with opioids is highly
recommended. Traditional views in treating nonmalignant pain Many
clinicians think that opioids are inappropriate therapy for chronic
nonmalignant pain. Reasons for such negative views include:
•addiction potential
•frequent side effects
•tolerance with long term use
•many nonresponsive pains
•chronic therapy contributes to disability
Clinical experience, combined with a critical reevaluation of these
concerns, suggests the existence of a subpopulation of patients who
could benefit from opioids (J Pain Symptom Manage 1996;11:203-217).
Addiction potential of opioids Opioids possess the potential for
producing addiction; however, pain specialists find very few cancer
patients becoming addicted to opioids. Physical dependence is not the
same as addiction. The definition for addiction needs to include loss of
control, compulsive use, and continued use in spite of harm.
Epidemiologic studies show a low risk of addiction to opioids taken by
patients with no history of substance abuse. For example, the 1980
survey by the Boston Collaborative Group found only 4/11,882 (0.03%)
patients became addicted to an opioid. This survey included patients
given an opioid for at least four months in a hospital setting. The
Perry and Heidrich survey on 10,000 burn center patients, treated with
opioids, failed to identify any patients as substance abusers.
Nevertheless, additional studies would help clarify the risk for
addiction to patients with chronic nonmalignant pain treated with
opioids.
Frequency of side effects Side effects occur frequently in
opioid-treated cancer patients but none of these cause major organ
dysfunction. The side effects appear early and patients quickly develop
tolerance to them. Since social and situational factors can influence
opioid effects, the need continues for information on drug-related
behaviors. Analgesic tolerance Therapeutic resistance is not a
characteristic of opioids. Absence of pain relief to increasing doses is
very uncommon. Nonresponsive pains Portenoy's review of the literature
found controlled trials and anecdotal reports supporting the use of
opioids for chronic nonmalignant pain. For example, the randomized,
cross-over, placebo-controlled study of Moulin et al (Lancet 1996;347
:143-7) showed nonneuropathic musculoskeletal pain significantly
lessened by controlled-release morphine sulfate. Published anecdotal
reports on over 1,000 patients support the clinical effectiveness of
opioids in nonmalignant pain. However, additional controlled studies are
needed to define the subpopulation of nonmalignant pain patients more
likely to benefit from opioid analgesics. /TD> Is chronic opioid therapy
disabling? Portenoy recommends keeping careful patient records as
progress notes as an alerting device during long-term treatment. Pain
severity needs to be measured minimally on a scale of mild, moderate and
severe. Does the patient experience side effects such as sedation,
constipation, or cognitive impairment? What is the patient's physical
and psychosocial status? Is there any drug-related aberrant behavior?
M. J. Kreek, MD, Rockefeller University, New York City, asked Portenoy
to recommend a course of action when encountering aberrant or addictive
behavior during treatment. Portenoy, an expert in pain management,
enlists a specialist in addiction disorders to jointly assess the
patient's behavior and develop a treatment regimen.
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For professional correspondence, please contact Dr. Portenoy at:
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Presented at the Conference on Pain Management and Chemical Dependency
on 22 Nov 1996
CONRAD NOTES © All Rights Reserved December 1996
Eugene A. Conrad, PhD, MPH / ISSN 1078 / posted on 1-Feb-1997
info from:
http://www.meds.com/conrad/pmcd/port3.html
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